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Three Villages Medical Practice Good

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Inspection Summary

Overall summary & rating


Updated 13 December 2017

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of Three Villages Medical Practice on 18 January 2017. The overall rating for the practice was good with requires improvement for providing a safe service. The full comprehensive report on the 18 January 2017 inspection can be found by selecting the ‘all reports’ link for Three Villages Medical Practice on our website at

This inspection was an announced focused inspection carried out on 10 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations identified at our previous inspection on 18 January 2017. This report covers our findings in relation to those requirements.

Our key findings were as follows:

  • An effective system had been implemented to ensure clinical alerts such as those from the Medicines and Healthcare products Regulatory Agency (MHRA) were communicated to appropriate staff and appropriate actions taken.
  • The practice had effective systems to manager patients experiencing poor mental health (including people with dementia).  

Further improvements included:

  • A strong relationship had been developed with the patient participation group and we saw that active engagement was supported and encouraged by the practice.
  • In 2017, the practice had achieved an increase in 18 of the 22 indicators that make up the annual National GP Survey.
  • Quality performance data for patient outcomes was consistently above average when compared to other local practices and overall performance positioned in the practice in the best quartile for Dudley Clinical Commissioning Group (CCG).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas



Updated 13 December 2017

The practice is rated as good for providing safe services.

  • The provider had implemented an effective system to receive and act on alerts. The system included repeat auditing to monitor if any new patients may be at risk.



Updated 13 December 2017



Updated 13 December 2017



Updated 13 December 2017



Updated 13 December 2017

Checks on specific services

People with long term conditions


Updated 21 April 2017

The practice is rated as good for the care of people with long-term conditions.

  • Nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.

  • Performance for diabetes related indicators was above the CCG and national averages. For example, 88% of patients diagnosed with diabetes had a blood sugar reading which showed that the condition was being controlled appropriately, compared to CCG and national average of 78%.

  • The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.

  • Patients had access to in-house electrocardiogram ECG (a test that can be used to check the heart's rhythm and electrical activity) and a blood pressure monitoring machine was available within the reception area. Staff explained that they had received positive reviews from patients, as they are no longer having to attend the local hospital.

  • There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health.

  • The practice offered a range of services in-house to support the diagnosis and monitoring of patients with long term conditions including spirometry, phlebotomy and followed recognised asthma pathways.

  • All these patients had a named GP and there was a system to recall patients for a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people


Updated 21 April 2017

The practice is rated as good for the care of families, children and young people.

  • The practice were able to demonstrate systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances.

  • Staff we spoke with were able to describe how they would ensure children and young people were treated in an age-appropriate way and that they would recognise them as individuals.

  • The practice’s uptake for the cervical screening programme was 83%, which was above the CCG average of 78% and the national average of 81%.

  • The practice provided support for premature babies and their families following discharge from hospital. For example, the practice held regular MDTs with health visitors; clinicians carried out six week new born baby examination and postnatal checks which included asking about postnatal depression. Immunisation rates were relatively high for all standard childhood immunisations.

  • Appointments were available outside of school hours and the premises were suitable for children and babies. Rooms were available for breast feeding and there were baby changing facilities.

  • The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics.

  • The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications.

  • GPs carried out weekly contraception clinics where a full range of contraceptive services was available. Staff we spoke with were able to demonstrate the use of Gillick competencies (a framework used to decide whether a child aged 16 years or younger is able to consent to his or her own medical treatment, without the need for parental permission or knowledge  when prescribing to under age patients).

Older people


Updated 21 April 2017

The practice is rated as good for the care of older people.

  • Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.

  • The practice offered proactive, personalised care to meet the needs of the older patients in its population. Social support via an Integrated plus referral was available and the practice had a supportive patient participation group which hosted tea parties.

  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. Clinicians carried out fortnightly ward rounds of local care homes and used a quality improvement stop and start tool for patients in receipt of four or more medicines.
  • The practice had a named lead who identified at an early stage older people who might need specialist care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.

  • The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.

  • Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible. For example, patients were sign posted to Age UK and also telephone support services such as Silver Line (a confidential, free helpline for older people across the UK that’s open 24 hours a day, seven days a week offering information, friendship; advice and links to local groups).

Working age people (including those recently retired and students)


Updated 21 April 2017

The practice is rated as good for the care of working age people (including those recently retired and students).

  • The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, extended opening hours and Saturday appointments were available to manage winter pressures.

  • The practice was proactive in offering online services, telephone consultations; test results were available online for those with patient access as well as a full range of health promotion and screening that reflects the needs for this age group.

  • Non NHS funded medicals such as Heavy Goods Vehicle (HGV) and taxi driver medicals were available within the practice.

  • Patients had access to physician associate appointments for acute on the day medical & surgical emergencies.

  • The practice offered travel vaccinations available on the NHS and staff sign posted patients to other services for travel vaccinations only available privately such as yellow fever centre (able to provide vaccination for a tropical virus disease transmitted by mosquitoes which affects the liver and kidneys).

  • The practice provided new patient health checks and routine NHS health checks for patients aged 40-74 years.

People experiencing poor mental health (including people with dementia)


Updated 13 December 2017

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

  • The practice had an appointed lead for mental health. We saw that the lead coordinated care internally as well as providing feedback to the clinical commissioning group (CCG).
  • The mental health lead was able to demonstrate a comprehensive management of patients on the mental health register.
  • Staff had received dementia training, dedicated dementia clinics had been introduced and the clinical dementia lead worked jointly with community dementia advisors.

People whose circumstances may make them vulnerable


Updated 21 April 2017

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.

  • The practice offered longer appointments for patients with a learning disability and the practice maintained close links with the local Learning Disability College. Data provided by the practice showed that annual reviews were carried out.

  • The practice regularly worked with other health care professionals in the case management of vulnerable patients. For example, they provided a shared care service in partnership with the local addiction service for patients with opiate dependency allowing them to obtain their medicine at the surgery.

  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.

  • Staff we spoke with knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.

  • A carers champion was in place to manage the practice carers list. Carers of patients registered with the practice had access to a range of services, for example annual health checks, flu vaccinations and a review of their stress levels. Data provided by the practice showed that 2% of the practice list were carers.